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Literature update January 2011

Ramsay CR, Thomas RE, Croal BL, Grimshaw JM, Eccles MP. Using the theory of planned behaviour as a process evaluation tool in randomised trials of knowledge translation strategies: A case study from UK primary care. Implement Sci. 2010 Sep 29;5:71. doi:10.1186/1748-5908-5-71

Background. Randomised trials of knowledge translation strategies for professional behaviour change can provide robust estimates of effectiveness, but offer little insight into the causal mechanisms by which any change is produced. To illustrate the applicability of causal methods within randomised trials, we undertook a theory-based process evaluation study within an implementation trial to explore whether the cognitions of primary care doctors' predicted their test requesting behaviours and, secondly, whether the trial results were mediated by the theoretical constructs. Methods. The process evaluation comprised a cross-sectional questionnaire survey of a random 50% sample of the randomised groups of primary care practices in Grampian (NHS Grampian), UK, who took part in a trial of the effect of enhanced feedback and brief educational reminders on test requesting behaviour. The process evaluation was based upon the Theory of Planned Behaviour and focussed on three of the test requesting behaviours that were targeted in the trial -- ferritin, follicle stimulating hormone (FSH), and Helicobacter Pylori serology (HPS). Results. The questionnaire was completed by 131 primary care doctors (56%) from 42 (98%) of the sampled practices. Behavioural intention, attitude, and subjective norm were highly correlated for all the tests. There was no evidence that perceived behavioural control was correlated with any of the other measures. Simple linear regression analysis of the rate of test requests on minimum behavioural intentions had R2 of 11.1%, 12.5%, and 0.1% for ferritin, FSH, and HPS requesting, respectively. Mediational analysis showed that the trial results for ferritin and FSH were partially mediated (between 23% and 78% mediation) through intentions. The HPS trial result was not mediated through intention. Conclusions. This study demonstrated that a theory-based process evaluation can provide useful information on causal mechanisms that aid not only interpretation of the trial but also inform future evaluations and intervention development.

Salbach NM, Guilcher SJ, Jaglal SB, Davis DA. Determinants of research use in clinical decision making among physical therapists providing services post-stroke: a cross-sectional study. Implement Sci. 2010 Oct 14;5:77. doi:10.1186/1748-5908-5-77

Background. Despite evidence of the benefits of research use in post-acute stroke rehabilitation where compliance with clinical practice guidelines has been associated with functional recovery and patient satisfaction, the rate of reliance on the research literature in clinical decision making among physical therapists is low. More research examining factors that motivate physical therapists to consider research findings in neurological practice is needed to inform efforts to intervene. The objective of this study was to identify practitioner, organizational, and research characteristics associated with research use among physical therapists providing services post-stroke. Methods. A cross-sectional mail survey of physical therapists providing services to people with stroke in Ontario, Canada was conducted. The survey questionnaire contained items to evaluate practitioner and organizational characteristics and perceptions of research considered to influence evidence-based practice (EBP), as well as the frequency of using research evidence in clinical decision making in a typical month. Ordinal regression was used to identify factors associated with research use. Results. The percentage of respondents reporting research use in clinical decision making 0 to 1, 2 to 5, or 6+ times in a typical month was 33.8%, 52.9%, and 13.3%, respectively (n = 263). Academic preparation in the principles of EBP, research participation, service as a clinical instructor, self-efficacy to implement EBP, a positive attitude towards research, perceived organizational support of research use, and Internet access to bibliographic databases at work were each associated with research use and placed in the final regression model. In the final model (n = 244), academic preparation in EBP, EBP self-efficacy, agreement that research findings are useful, and research participation each remained significantly associated with research use after adjusting for the effects of the other variables in the model. Conclusions. A third of therapists rarely use research evidence in clinical decision making. Education in the principles of EBP, EBP self-efficacy, a positive attitude towards research, and involvement in research at work may promote research use in neurological physical therapy practice. Future research is needed to confirm these findings and to determine the type of research participation that may promote research use.

Helfrich CD, Damschroder LJ, Hagedorn HJ, Daggett GS, Sahay A, Ritchie M, Damush T, Guihan M, Ullrich PM, Stetler CB.A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework. Implement Sci. 2010 Oct 25;5:82. doi:10.1186/1748-5908-5-82

Background. The Promoting Action on Research Implementation in Health Services framework, or PARIHS, is a conceptual framework that posits key, interacting elements that influence successful implementation of evidence-based practices. It has been widely cited and used as the basis for empirical work; however, there has not yet been a literature review to examine how the framework has been used in implementation projects and research. The purpose of the present article was to critically review and synthesize the literature on PARIHS to understand how it has been used and operationalized, and to highlight its strengths and limitations. Methods. We conducted a qualitative, critical synthesis of peer-reviewed PARIHS literature published through March 2009. We synthesized findings through a three-step process using semi-structured data abstraction tools and group consensus. Results. Twenty-four articles met our inclusion criteria: six core concept articles from original PARIHS authors, and eighteen empirical articles ranging from case reports to quantitative studies. Empirical articles generally used PARIHS as an organizing framework for analyses. No studies used PARIHS prospectively to design implementation strategies, and there was generally a lack of detail about how variables were measured or mapped, or how conclusions were derived. Several studies used findings to comment on the framework in ways that could help refine or validate it. The primary issue identified with the framework was a need for greater conceptual clarity regarding the definition of sub-elements and the nature of dynamic relationships. Strengths identified included its flexibility, intuitive appeal, explicit acknowledgement of the outcome of 'successful implementation,' and a more expansive view of what can and should constitute 'evidence.' Conclusions. While we found studies reporting empirical support for PARIHS, the single greatest need for this and other implementation models is rigorous, prospective use of the framework to guide implementation projects. There is also need to better explain derived findings and how interventions or measures are mapped to specific PARIHS elements; greater conceptual discrimination among sub-elements may be necessary first. In general, it may be time for the implementation science community to develop consensus guidelines for reporting the use and usefulness of theoretical frameworks within implementation studies.

De Allegri M, Schwarzbach M, Loerbroks A, Ronellenfitsch U. Which factors are important for the successful development and implementation of clinical pathways? A qualitative study. Qual Saf Health Care. 2011 Jan 5. [Epub ahead of print]

Introduction Clinical pathways (CPs) are detailed longitudinal care plans delineating measures to be conducted during a patient's treatment. Although positive effects on resource consumption and quality of care have been shown, CPs are still underutilised in many clinical settings because their development and implementation are difficult. Evidence underpinning successful development and implementation is sparse. Methods The authors conducted semistructured face-to-face interviews with key staff members involved in the design and implementation of CPs in a large surgery department. Interviewees were asked to provide opinions on various issues, which were previously identified as potentially important in CP development and implementation. The transcribed text was read and coded independently by two researchers. Results Respondents highlighted the importance of a multidisciplinary participatory approach for CP design and implementation. There was a strong initial fear of losing individual freedom of treatment, which subsided after people worked with CPs in clinical everyday life. It was appreciated that the project originated from people at different levels of the department's hierarchy. Likewise, it was felt that CP implementation granted more autonomy to lower-level staff. Conclusion The structured qualitative approach of this study provides information on what issues are considered important by staff members for CP design and implementation. Whereas some concepts such as the importance of a multidisciplinary approach or continuous feedback of results are known from theories, others such as strengthening the authority especially of lower-level health professionals through CPs have not been described so far. Many of the findings point towards strong interactions between factors important for CP implementation and a department's organisational structure.

Carlsen B, Bringedal B. Attitudes to clinical guidelines—do GPs differ from other medical doctors? Qual Saf Health Care. 2011 Jan 5. [Epub ahead of print]

Background Clinical guidelines are important for ensuring quality of treatment and care. For this reason, it is essential that clinicians adhere to guidelines. Review studies conclude that barriers to using guidelines are context specific. Nevertheless, there is a lack of studies that compare the attitudes of different groups of doctors to guidelines. Objectives To survey the attitudes of Norwegian medical practitioners to clinical guidelines and the reasons for any scepticism, and to compare general practitioners (GPs) with other medical doctors in Norway in this respect. Method Postal questionnaire to a panel of 1649 Norwegian medical doctors. Results 1072 doctors responded (65%). 97% claimed to be familiar with and following guidelines. A majority expressed confidence in guidelines issued by the health authorities and the medical association. GPs are significantly more uncertain about the legal status of, accessibility of and evidence in guidelines than other doctors. The most important barriers to guideline adherence are concerns about the uniqueness of individual cases and reliance on one's own professional discretion. Both groups rank attitudinal constraints higher than practical constraints, but GPs more often report practical issues as reasons for non-adherence. Conclusion It is suggested that creating trust in guidelines could be more important than more efforts to improve guideline format and accessibility. It may also be worth considering whether guidelines should be implemented using different processes in generalist and specialist care.

Ebell M. AHRQ White Paper: Use of Clinical Decision Rules for Point-of-Care Decision Support. Med Decis Making. 2010 Nov-Dec;30(6):712-21. doi: 10.1177/0272989X10386232

Translation of research into clinical practice remains a barrier, with inconsistent adoption of effective treatments and useful tests. Clinical decision rules (CDRs) integrate information from several clinical or laboratory findings to provide quantitative estimates of risk for a diagnosis or clinical outcome. They are increasingly reported in the literature and have the potential to provide a bridge that helps translate findings from original research studies into clinical practice. Unlike formal aids for shared decision making, they are pragmatic solutions that provide discrete quantitative data to aid clinicians and patients in decision making. These quantitative data can help inform the informal episodes of shared decision making that frequently take place at the point of care. Methods used to develop CDRs include expert opinion, multivariate models, point scores, and classification and regression trees Desirable CDRs are valid (make accurate predictions of risk), relevant (have been shown to improve patient-oriented outcomes), are easy to use at the point of care, are acceptable (with good face validity and transparency of recommendations), and are situated in the clinical context. The latter means that the rule places patients in risk groups that are clinically useful (i.e., below the test threshold or above the treatment threshold) and does so in adequate numbers to make use of the CDR a worthwhile investment in time. CDRs meeting these criteria should be integrated with electronic health records, populating the point score or decision tree with individual patient data and performing calculations automatically to streamline decision making.

Naik AD, Singh H. Electronic Health Records to Coordinate Decision Making for Complex Patients: What Can We Learn from Wiki? Med Decis Making 2010 Nov-Dec;30(6):722-31. doi: 10.1177/0272989X10385846

Background. Processes of communication that guide decision making among clinicians collaboratively caring for complex patients are poorly understood and vary based on local contexts. In this paper, the authors characterize these processes and propose a wiki-style communication model to improve coordination of decision making among clinicians using an integrated electronic health record (EHR). Methods. A narrative review of current patterns of communication among clinicians sharing medical decisions focusing on the emerging and potential roles of EHRs to enhance communication among clinicians caring for complex patients. Results. The authors present the taxonomy of decision making and communication among clinicians caring for complex patients. They then adapt wiki-style communication to propose a novel model of communication among clinicians for decision making within multidisciplinary disease management programs. Future innovations using wiki-style communication among clinicians are also described and placed in the context of medical decisions by clinicians working together in disease management programs. Conclusions. EHR-based wiki-style applications may have the potential to improve communication and care coordination among clinicians caring for complex patients. This could lead to improved quality and safety within multidisciplinary disease management programs.

To T, Guttmann A, Lougheed MD, Gershon AS, Dell SD, Stanbrook MB, Wang C, McLimont S, Vasilevska-Ristovska J, Crighton EJ, Fisman DN. Evidence-based performance indicators of primary care for asthma: a modified RAND Appropriateness Method. Int J Qual Health Care 2010 Dec;22(6):476-85. doi: 10.1093/intqhc/mzq061

Purpose To develop evidence-based performance indicators that measure the quality of primary care for asthma. Data sources Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and CINAHL for peer-reviewed articles published in 1998–2008 and five national/global asthma management guidelines. Study selection Articles with a focus on current asthma performance indicators recognized or used in community and primary care settings. Data extraction Modified RAND Appropriateness Method was used. The work described herein was conducted in Canada in 2008. Five clinician experts conducted the systematic literature review. Asthma-specific performance indicators were developed and the strength of supporting evidence summarized. A survey was created and mailed to 17 expert panellists of various disciplines, asking them to rate each indicator using a 9-point Likert scale. Percentage distribution of the Likert scores were generated and given to the panellists before a face-to-face meeting, which was held to assess consensus. At the meeting, they ranked all indicators based on their reliability, validity, availability and feasibility. Results Literature search yielded 1228 articles, of which 135 were used to generate 45 performance indicators in five domains: access to care, clinical effectiveness, patient centeredness, system integration and coordination and patient safety. The top five ranked indicators were: Asthma Education from Certified Asthma Educator, Pulmonary Function Monitoring, Asthma Control Monitoring, Controller Medication Use and Asthma Control. Conclusion The top 15 ranked indicators are recommended for implementation in primary care to measure asthma care delivery, respiratory health outcomes and establish benchmarks for optimal health service delivery over time and across populations.

Knops AM, Storm-Versloot MN, Mank AP, Ubbink DT, Vermeulen H, Bossuyt PM, Goossens A. Factors influencing long-term adherence to two previously implemented hospital guidelines. Int J Qual Health Care 2010 Oct;22(5):421-9. doi: 10.1093/intqhc/mzq038

Objective and Setting After successful implementation, adherence to hospital guidelines should be sustained. Long-term adherence to two hospital guidelines was audited. The overall aim was to explore factors accounting for their long-term adherence or non-adherence. Design and Participants A fluid balance guideline (FBG) and body temperature guideline (BTG) were developed and implemented in our hospital in 2000. Long-term adherence was determined retrospectively based on data from patient files. Focus groups were launched to explore nurses' perceptions of barriers and facilitators regarding long-term adherence. The predominant themes from the nurses' focus groups were posed to clinicians in questionnaires. Results Nurses involved in the FBG (overall adherence 100%) stated that adherence has immediate advantages in terms of safety and a gain in time. Nurses and oncologists acted unanimously which was thought to enhance adherence. On the other hand, opinions differed on the BTG within the nursing teams and medical staff (overall adherence 50%). Although the guideline discourages routine postoperative body temperature measurements, temperature should be measured according to the guideline in a considerable number of cases due to changes in patient characteristics since the year 2000. Therefore, adherence was judged to be rather complex. Conclusions To secure adherence to hospital guidelines after their successful implementation, guidelines should preferably be comprehensive in terms of being applicable to the majority of the patients in that particular setting and to the most common clinical situations. All healthcare professionals involved should be aware of its immediate benefits for themselves or to their patients.

Tomasik T. Reliability and validity of the Delphi method in guideline development for family physicians. Qual Prim Care, 2010;18(5):317-26.

Background: The aim of this study was to assess the reliability and validity of the Delphi method in preparing hypertension guidelines for family physicians in Poland. Methods: A two-round Delphi method was used to develop guidelines for management of hypertension by the College of Family Physicians in Poland. The respondent group consisted of 36 family physicians and 19 specialists. To assess reliability, the internal correlation coefficient (Cronbach's alpha) was calculated for both rounds. Criterion validity was examined by comparing recommendations in the guidelines with scientific evidence from a study in the Medline database. The content validity was estimated by measurement of extent to which recommendations were related to the competences of family physicians in Poland. To calculate construct validity, a comparison between the results obtained by the Delphi method with those of other methods was performed (Holley and Guilford (G) index). Results: Reliability (Cronbach's alpha) was 0.944 for round one and 0.850 for round two. The five missing recommendations and contrary evidence for one recommendation indicated that criterion validity was fulfilled only in part. Among 28 routine tasks related to hypertension carried out by family physicians, the guidelines contained no recommendations for five (17.9%) of them. This indicated that content validity was only satisfactory, whereas construct validity was good (Holley and Guilford (G) index 0.39-0.65). Conclusion: The Delphi method in the form used in Poland for preparing hypertension guidelines showed good reliability and satisfactory validity. The method should be used judiciously and only after careful preparation.

Turner T, Harris C, Green S. A pragmatic model for evidence-based guideline development in hospitals. Clinical Governance: An International Journal, 2010;15 (4):255-265

Purpose- Existing methods of development of evidence-based guidelines are time-consuming, resource-intensive and require extensive skills in systematic reviewing. These factors act as barriers to development of evidence-based guidelines in hospitals. The aim of this paper is to revise the existing method of development of evidence-based guidelines to create a new pragmatic model that was feasible in hospital settings. Design/methodology/approach- The model consists of eight steps: scope, prioritise, search, appraise, draft, consult, disseminate and update. These steps largely parallel the established guideline development process, but suggest more focused, pragmatic methods. Findings- The "prioritise" step is a new step. Other differences include: guideline development by an individual or small group rather than a large multidisciplinary group; searching for evidence for only a limited number of priority decision points rather than for all decision points; searching only in a limited number of sources likely to provide high quality research rather than searching very broadly; searching only for high-quality research which is less open to bias rather than searching for all forms of research evidence; including only research evidence which can be easily accessed in full text, rather than investing time in tracking down research which is difficult to obtain; and only involving consumers in guideline development where an existing mechanism for consumer involvement exists. Originality/value- This new, pragmatic guideline development model aims to overcome the substantial barriers to guideline development in hospital settings. This model needs to be tested to determine if it is feasible and produces guidelines that are trustworthy.

Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L, and for the AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care Can. Med. Assoc. J. 182: E839-842E.

 

Williams RJ, Tse T, Harlan WR, Zarin DA. Registration of observational studies: Is it time? Can. Med. Assoc. J. 182: 1638-1642.

 

Guyatt G, Akl EA, Hirsh J, Kearon C, Crowther M, Gutterman D, Lewis SZ, Nathanson I, Jaeschke R, Schünemann H. The Vexing Problem of Guidelines and Conflict of Interest: A Potential Solution. Ann Intern Med. 2010 Jun 1;152(11):738-41.

Issues of financial and intellectual conflict of interest in clinical practice guidelines have raised increasing concern. Professional organizations have responded by more rigorous regulation of conflict of interest. Nevertheless, tension remains between the competing goals of optimizing guideline quality by using the experience and insight of experts and ensuring that financial and intellectual conflicts of interest do not influence recommendations. The executive committee of the American College of Chest Physicians' Antithrombotic Guidelines has developed a strategy comprising 3 innovative aspects to address this tension: First, place equal emphasis on intellectual and financial conflicts and provide explicit criteria for both; second, a methodologist without important conflicts of interest should have primary responsibility for each chapter; and third, experts with important financial or intellectual conflicts of interest can collect and interpret evidence, but only panel members without important conflicts can be involved in developing the recommendation for a specific question. These strategies may help to achieve the benefits of expert input without conflicts of interest influencing recommendations.

Implement Sci. 2010 Sep 29;5:71. Using the theory of planned behaviour as a process evaluation tool in randomised trials of knowledge translation strategies: A case study from UK primary care. Ramsay CR, Thomas RE, Croal BL, Grimshaw JM, Eccles MP. doi:10.1186/1748-5908-5-71


Background. Randomised trials of knowledge translation strategies for professional behaviour change can provide robust estimates of effectiveness, but offer little insight into the causal mechanisms by which any change is produced. To illustrate the applicability of causal methods within randomised trials, we undertook a theory-based process evaluation study within an implementation trial to explore whether the cognitions of primary care doctors' predicted their test requesting behaviours and, secondly, whether the trial results were mediated by the theoretical constructs. Methods. The process evaluation comprised a cross-sectional questionnaire survey of a random 50% sample of the randomised groups of primary care practices in Grampian (NHS Grampian), UK, who took part in a trial of the effect of enhanced feedback and brief educational reminders on test requesting behaviour. The process evaluation was based upon the Theory of Planned Behaviour and focussed on three of the test requesting behaviours that were targeted in the trial -- ferritin, follicle stimulating hormone (FSH), and Helicobacter Pylori serology (HPS). Results. The questionnaire was completed by 131 primary care doctors (56%) from 42 (98%) of the sampled practices. Behavioural intention, attitude, and subjective norm were highly correlated for all the tests. There was no evidence that perceived behavioural control was correlated with any of the other measures. Simple linear regression analysis of the rate of test requests on minimum behavioural intentions had R2 of 11.1%, 12.5%, and 0.1% for ferritin, FSH, and HPS requesting, respectively. Mediational analysis showed that the trial results for ferritin and FSH were partially mediated (between 23% and 78% mediation) through intentions. The HPS trial result was not mediated through intention. Conclusions. This study demonstrated that a theory-based process evaluation can provide useful information on causal mechanisms that aid not only interpretation of the trial but also inform future evaluations and intervention development.

 

Salbach NM, Guilcher SJ, Jaglal SB, Davis DA. Determinants of research use in clinical decision making among physical therapists providing services post-stroke: a cross-sectional study. Implement Sci. 2010 Oct 14;5:77. doi:10.1186/1748-5908-5-77


Background. Despite evidence of the benefits of research use in post-acute stroke rehabilitation where compliance with clinical practice guidelines has been associated with functional recovery and patient satisfaction, the rate of reliance on the research literature in clinical decision making among physical therapists is low. More research examining factors that motivate physical therapists to consider research findings in neurological practice is needed to inform efforts to intervene. The objective of this study was to identify practitioner, organizational, and research characteristics associated with research use among physical therapists providing services post-stroke. Methods. A cross-sectional mail survey of physical therapists providing services to people with stroke in Ontario, Canada was conducted. The survey questionnaire contained items to evaluate practitioner and organizational characteristics and perceptions of research considered to influence evidence-based practice (EBP), as well as the frequency of using research evidence in clinical decision making in a typical month. Ordinal regression was used to identify factors associated with research use. Results. The percentage of respondents reporting research use in clinical decision making 0 to 1, 2 to 5, or 6+ times in a typical month was 33.8%, 52.9%, and 13.3%, respectively (n = 263). Academic preparation in the principles of EBP, research participation, service as a clinical instructor, self-efficacy to implement EBP, a positive attitude towards research, perceived organizational support of research use, and Internet access to bibliographic databases at work were each associated with research use and placed in the final regression model. In the final model (n = 244), academic preparation in EBP, EBP self-efficacy, agreement that research findings are useful, and research participation each remained significantly associated with research use after adjusting for the effects of the other variables in the model. Conclusions. A third of therapists rarely use research evidence in clinical decision making. Education in the principles of EBP, EBP self-efficacy, a positive attitude towards research, and involvement in research at work may promote research use in neurological physical therapy practice. Future research is needed to confirm these findings and to determine the type of research participation that may promote research use.

 

Helfrich CD, Damschroder LJ, Hagedorn HJ, Daggett GS, Sahay A, Ritchie M, Damush T, Guihan M, Ullrich PM, Stetler CB.A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework. Implement Sci. 2010 Oct 25;5:82. doi:10.1186/1748-5908-5-82


Background. The Promoting Action on Research Implementation in Health Services framework, or PARIHS, is a conceptual framework that posits key, interacting elements that influence successful implementation of evidence-based practices. It has been widely cited and used as the basis for empirical work; however, there has not yet been a literature review to examine how the framework has been used in implementation projects and research. The purpose of the present article was to critically review and synthesize the literature on PARIHS to understand how it has been used and operationalized, and to highlight its strengths and limitations. Methods. We conducted a qualitative, critical synthesis of peer-reviewed PARIHS literature published through March 2009. We synthesized findings through a three-step process using semi-structured data abstraction tools and group consensus. Results. Twenty-four articles met our inclusion criteria: six core concept articles from original PARIHS authors, and eighteen empirical articles ranging from case reports to quantitative studies. Empirical articles generally used PARIHS as an organizing framework for analyses. No studies used PARIHS prospectively to design implementation strategies, and there was generally a lack of detail about how variables were measured or mapped, or how conclusions were derived. Several studies used findings to comment on the framework in ways that could help refine or validate it. The primary issue identified with the framework was a need for greater conceptual clarity regarding the definition of sub-elements and the nature of dynamic relationships. Strengths identified included its flexibility, intuitive appeal, explicit acknowledgement of the outcome of 'successful implementation,' and a more expansive view of what can and should constitute 'evidence.' Conclusions. While we found studies reporting empirical support for PARIHS, the single greatest need for this and other implementation models is rigorous, prospective use of the framework to guide implementation projects. There is also need to better explain derived findings and how interventions or measures are mapped to specific PARIHS elements; greater conceptual discrimination among sub-elements may be necessary first. In general, it may be time for the implementation science community to develop consensus guidelines for reporting the use and usefulness of theoretical frameworks within implementation studies.

 

De Allegri M, Schwarzbach M, Loerbroks A, Ronellenfitsch U. Which factors are important for the successful development and implementation of clinical pathways? A qualitative study. Qual Saf Health Care. 2011 Jan 5. [Epub ahead of print]

Introduction Clinical pathways (CPs) are detailed longitudinal care plans delineating measures to be conducted during a patient's treatment. Although positive effects on resource consumption and quality of care have been shown, CPs are still underutilised in many clinical settings because their development and implementation are difficult. Evidence underpinning successful development and implementation is sparse. Methods The authors conducted semistructured face-to-face interviews with key staff members involved in the design and implementation of CPs in a large surgery department. Interviewees were asked to provide opinions on various issues, which were previously identified as potentially important in CP development and implementation. The transcribed text was read and coded independently by two researchers. Results Respondents highlighted the importance of a multidisciplinary participatory approach for CP design and implementation. There was a strong initial fear of losing individual freedom of treatment, which subsided after people worked with CPs in clinical everyday life. It was appreciated that the project originated from people at different levels of the department's hierarchy. Likewise, it was felt that CP implementation granted more autonomy to lower-level staff. Conclusion The structured qualitative approach of this study provides information on what issues are considered important by staff members for CP design and implementation. Whereas some concepts such as the importance of a multidisciplinary approach or continuous feedback of results are known from theories, others such as strengthening the authority especially of lower-level health professionals through CPs have not been described so far. Many of the findings point towards strong interactions between factors important for CP implementation and a department's organisational structure.

 

Carlsen B, Bringedal B. Attitudes to clinical guidelines—do GPs differ from other medical doctors? Qual Saf Health Care. 2011 Jan 5. [Epub ahead of print]

Background Clinical guidelines are important for ensuring quality of treatment and care. For this reason, it is essential that clinicians adhere to guidelines. Review studies conclude that barriers to using guidelines are context specific. Nevertheless, there is a lack of studies that compare the attitudes of different groups of doctors to guidelines. Objectives To survey the attitudes of Norwegian medical practitioners to clinical guidelines and the reasons for any scepticism, and to compare general practitioners (GPs) with other medical doctors in Norway in this respect. Method Postal questionnaire to a panel of 1649 Norwegian medical doctors. Results 1072 doctors responded (65%). 97% claimed to be familiar with and following guidelines. A majority expressed confidence in guidelines issued by the health authorities and the medical association. GPs are significantly more uncertain about the legal status of, accessibility of and evidence in guidelines than other doctors. The most important barriers to guideline adherence are concerns about the uniqueness of individual cases and reliance on one's own professional discretion. Both groups rank attitudinal constraints higher than practical constraints, but GPs more often report practical issues as reasons for non-adherence. Conclusion It is suggested that creating trust in guidelines could be more important than more efforts to improve guideline format and accessibility. It may also be worth considering whether guidelines should be implemented using different processes in generalist and specialist care.

 

Ebell M. AHRQ White Paper: Use of Clinical Decision Rules for Point-of-Care Decision Support. Med Decis Making. 2010 Nov-Dec;30(6):712-21. doi: 10.1177/0272989X10386232

Translation of research into clinical practice remains a barrier, with inconsistent adoption of effective treatments and useful tests. Clinical decision rules (CDRs) integrate information from several clinical or laboratory findings to provide quantitative estimates of risk for a diagnosis or clinical outcome. They are increasingly reported in the literature and have the potential to provide a bridge that helps translate findings from original research studies into clinical practice. Unlike formal aids for shared decision making, they are pragmatic solutions that provide discrete quantitative data to aid clinicians and patients in decision making. These quantitative data can help inform the informal episodes of shared decision making that frequently take place at the point of care. Methods used to develop CDRs include expert opinion, multivariate models, point scores, and classification and regression trees Desirable CDRs are valid (make accurate predictions of risk), relevant (have been shown to improve patient-oriented outcomes), are easy to use at the point of care, are acceptable (with good face validity and transparency of recommendations), and are situated in the clinical context. The latter means that the rule places patients in risk groups that are clinically useful (i.e., below the test threshold or above the treatment threshold) and does so in adequate numbers to make use of the CDR a worthwhile investment in time. CDRs meeting these criteria should be integrated with electronic health records, populating the point score or decision tree with individual patient data and performing calculations automatically to streamline decision making.

Naik AD, Singh H. Electronic Health Records to Coordinate Decision Making for Complex Patients: What Can We Learn from Wiki? Med Decis Making 2010 Nov-Dec;30(6):722-31. doi: 10.1177/0272989X10385846

Background. Processes of communication that guide decision making among clinicians collaboratively caring for complex patients are poorly understood and vary based on local contexts. In this paper, the authors characterize these processes and propose a wiki-style communication model to improve coordination of decision making among clinicians using an integrated electronic health record (EHR). Methods. A narrative review of current patterns of communication among clinicians sharing medical decisions focusing on the emerging and potential roles of EHRs to enhance communication among clinicians caring for complex patients. Results. The authors present the taxonomy of decision making and communication among clinicians caring for complex patients. They then adapt wiki-style communication to propose a novel model of communication among clinicians for decision making within multidisciplinary disease management programs. Future innovations using wiki-style communication among clinicians are also described and placed in the context of medical decisions by clinicians working together in disease management programs. Conclusions. EHR-based wiki-style applications may have the potential to improve communication and care coordination among clinicians caring for complex patients. This could lead to improved quality and safety within multidisciplinary disease management programs.

 

To T, Guttmann A, Lougheed MD, Gershon AS, Dell SD, Stanbrook MB, Wang C, McLimont S, Vasilevska-Ristovska J, Crighton EJ, Fisman DN. Evidence-based performance indicators of primary care for asthma: a modified RAND Appropriateness Method. Int J Qual Health Care 2010 Dec;22(6):476-85. doi: 10.1093/intqhc/mzq061

Purpose To develop evidence-based performance indicators that measure the quality of primary care for asthma. Data sources Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and CINAHL for peer-reviewed articles published in 1998–2008 and five national/global asthma management guidelines. Study selection Articles with a focus on current asthma performance indicators recognized or used in community and primary care settings. Data extraction Modified RAND Appropriateness Method was used. The work described herein was conducted in Canada in 2008. Five clinician experts conducted the systematic literature review. Asthma-specific performance indicators were developed and the strength of supporting evidence summarized. A survey was created and mailed to 17 expert panellists of various disciplines, asking them to rate each indicator using a 9-point Likert scale. Percentage distribution of the Likert scores were generated and given to the panellists before a face-to-face meeting, which was held to assess consensus. At the meeting, they ranked all indicators based on their reliability, validity, availability and feasibility. Results Literature search yielded 1228 articles, of which 135 were used to generate 45 performance indicators in five domains: access to care, clinical effectiveness, patient centeredness, system integration and coordination and patient safety. The top five ranked indicators were: Asthma Education from Certified Asthma Educator, Pulmonary Function Monitoring, Asthma Control Monitoring, Controller Medication Use and Asthma Control. Conclusion The top 15 ranked indicators are recommended for implementation in primary care to measure asthma care delivery, respiratory health outcomes and establish benchmarks for optimal health service delivery over time and across populations.

 

Knops AM, Storm-Versloot MN, Mank AP, Ubbink DT, Vermeulen H, Bossuyt PM, Goossens A. Factors influencing long-term adherence to two previously implemented hospital guidelines. Int J Qual Health Care 2010 Oct;22(5):421-9. doi: 10.1093/intqhc/mzq038

Objective and Setting After successful implementation, adherence to hospital guidelines should be sustained. Long-term adherence to two hospital guidelines was audited. The overall aim was to explore factors accounting for their long-term adherence or non-adherence. Design and Participants A fluid balance guideline (FBG) and body temperature guideline (BTG) were developed and implemented in our hospital in 2000. Long-term adherence was determined retrospectively based on data from patient files. Focus groups were launched to explore nurses' perceptions of barriers and facilitators regarding long-term adherence. The predominant themes from the nurses' focus groups were posed to clinicians in questionnaires. Results Nurses involved in the FBG (overall adherence 100%) stated that adherence has immediate advantages in terms of safety and a gain in time. Nurses and oncologists acted unanimously which was thought to enhance adherence. On the other hand, opinions differed on the BTG within the nursing teams and medical staff (overall adherence 50%). Although the guideline discourages routine postoperative body temperature measurements, temperature should be measured according to the guideline in a considerable number of cases due to changes in patient characteristics since the year 2000. Therefore, adherence was judged to be rather complex. Conclusions To secure adherence to hospital guidelines after their successful implementation, guidelines should preferably be comprehensive in terms of being applicable to the majority of the patients in that particular setting and to the most common clinical situations. All healthcare professionals involved should be aware of its immediate benefits for themselves or to their patients.

Tomasik T. Reliability and validity of the Delphi method in guideline development for family physicians. Qual Prim Care, 2010;18(5):317-26.

Background: The aim of this study was to assess the reliability and validity of the Delphi method in preparing hypertension guidelines for family physicians in Poland. Methods: A two-round Delphi method was used to develop guidelines for management of hypertension by the College of Family Physicians in Poland. The respondent group consisted of 36 family physicians and 19 specialists. To assess reliability, the internal correlation coefficient (Cronbach's alpha) was calculated for both rounds. Criterion validity was examined by comparing recommendations in the guidelines with scientific evidence from a study in the Medline database. The content validity was estimated by measurement of extent to which recommendations were related to the competences of family physicians in Poland. To calculate construct validity, a comparison between the results obtained by the Delphi method with those of other methods was performed (Holley and Guilford (G) index). Results: Reliability (Cronbach's alpha) was 0.944 for round one and 0.850 for round two. The five missing recommendations and contrary evidence for one recommendation indicated that criterion validity was fulfilled only in part. Among 28 routine tasks related to hypertension carried out by family physicians, the guidelines contained no recommendations for five (17.9%) of them. This indicated that content validity was only satisfactory, whereas construct validity was good (Holley and Guilford (G) index 0.39-0.65). Conclusion: The Delphi method in the form used in Poland for preparing hypertension guidelines showed good reliability and satisfactory validity. The method should be used judiciously and only after careful preparation.

 

Turner T, Harris C, Green S. A pragmatic model for evidence-based guideline development in hospitals. Clinical Governance: An International Journal, 2010;15 (4):255-265

Purpose- Existing methods of development of evidence-based guidelines are time-consuming, resource-intensive and require extensive skills in systematic reviewing. These factors act as barriers to development of evidence-based guidelines in hospitals. The aim of this paper is to revise the existing method of development of evidence-based guidelines to create a new pragmatic model that was feasible in hospital settings. Design/methodology/approach- The model consists of eight steps: scope, prioritise, search, appraise, draft, consult, disseminate and update. These steps largely parallel the established guideline development process, but suggest more focused, pragmatic methods. Findings- The "prioritise" step is a new step. Other differences include: guideline development by an individual or small group rather than a large multidisciplinary group; searching for evidence for only a limited number of priority decision points rather than for all decision points; searching only in a limited number of sources likely to provide high quality research rather than searching very broadly; searching only for high-quality research which is less open to bias rather than searching for all forms of research evidence; including only research evidence which can be easily accessed in full text, rather than investing time in tracking down research which is difficult to obtain; and only involving consumers in guideline development where an existing mechanism for consumer involvement exists. Originality/value- This new, pragmatic guideline development model aims to overcome the substantial barriers to guideline development in hospital settings. This model needs to be tested to determine if it is feasible and produces guidelines that are trustworthy.

 

Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L, and for the AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care Can. Med. Assoc. J. 182: E839-842E.

 

Williams RJ, Tse T, Harlan WR, Zarin DA. Registration of observational studies: Is it time? Can. Med. Assoc. J. 182: 1638-1642.

 

Guyatt G, Akl EA, Hirsh J, Kearon C, Crowther M, Gutterman D, Lewis SZ, Nathanson I, Jaeschke R, Schünemann H. The Vexing Problem of Guidelines and Conflict of Interest: A Potential Solution. Ann Intern Med. 2010 Jun 1;152(11):738-41.

Issues of financial and intellectual conflict of interest in clinical practice guidelines have raised increasing concern. Professional organizations have responded by more rigorous regulation of conflict of interest. Nevertheless, tension remains between the competing goals of optimizing guideline quality by using the experience and insight of experts and ensuring that financial and intellectual conflicts of interest do not influence recommendations. The executive committee of the American College of Chest Physicians' Antithrombotic Guidelines has developed a strategy comprising 3 innovative aspects to address this tension: First, place equal emphasis on intellectual and financial conflicts and provide explicit criteria for both; second, a methodologist without important conflicts of interest should have primary responsibility for each chapter; and third, experts with important financial or intellectual conflicts of interest can collect and interpret evidence, but only panel members without important conflicts can be involved in developing the recommendation for a specific question. These strategies may help to achieve the benefits of expert input without conflicts of interest influencing recommendations.

 
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